. 2018 Nov 5;2018(11):CD012324. doi: 10.1002/14651858.CD012324.pub2

Summary of findings 2. Summary of findings: Picture Exchange Communication System (PECS) versus treatment as usual for minimally verbal children with autism spectrum disorder.

Picture Exchange Communication System (PECS) versus treatment as usual for minimally verbal children with autism spectrum disorder
Patient or population: minimally verbal children with autism spectrum disorder Settings: school (autism‐specific schools and units in South East London, UK) Intervention: PECS (teacher training and consultation; 2 groups: immediate treatment group and delayed treatment group) Comparison: control (classes where teachers had not received any active direct, in class training/consultancy with PECS consultants)
Outcomes	*Relative effect (95% CI)**	Number of participants (studies)	Quality of the evidence (GRADE)
Spoken communication Measured by: frequency of speech, including non‐word vocalisations (expressed as rates per minute)^a Follow‐up: 2 school terms^b	There was no significant main effect of the PECS intervention on frequency of speech (OR 1.10, 95% CI 0.46 to 2.62, P = 0.83)	84 (1 RCT)	⊕⊝⊝⊝  Very low^c,d
Non‐verbal communication/AAC Measured by: frequency of use of PECS symbols (expressed as rates per minute)^a Follow‐up: 2 school terms^b	Children in the PECS group were 3.90 times more likely to be in a higher PECS‐use category than children in the control group (OR 3.90, 95% CI 1.75 to 8.68, P < 0.001)	84 (1 RCT)	⊕⊝⊝⊝  Very low^c,d
Combined spoken and non‐verbal communication/AAC Measured by: verbal and non‐verbal initiations (expressed as rates per minute)^a Follow‐up: 2 school terms^b	Children in the PECS group were 2.73 times (OR 2.73, 95% CI 1.22 to 6.08, P < 0.05 (specific P value not reported in paper)) more likely to to be in the higher initiation‐rate category than the control group	84 (1 RCT)	⊕⊝⊝⊝  Very low^c,d
Adverse events	No data were reported for this outcome
Social communication or pragmatic language Measured by: reciprocal social interaction (ADOS‐G domain scores)^a Follow‐up: 2 school terms^b	There was no significant main effect of the PECS intervention on reciprocal social interaction OR 0.55 (95% CI 0.25 to 1.19, P = 0.13)	84 (1 RCT)	⊕⊝⊝⊝  Very low^c,d
Other communication skills	No data were reported for this outcome
Quality of life for the individual or their family and parent satisfaction	No data were reported for this outcome
Non‐core aspects of behaviour and function	No data were reported for this outcome
The relative risk (and its 95% CI) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
AACADOS‐G: Autism Diagnostic Observation Schedule ‐ Generic; CI: Confidence interval; OR: odds ratio; PECS: Picture Exchange Communication System; RCT: Randomised controlled trial.
GRADE Working Group grades of evidence  High quality: we are very confident that the true effect lies close to that of the estimate of the effect.  Moderate quality: we are moderately confident in the effect estimate; the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different.  Low quality: our confidence in the effect estimate is limited; the true effect may be substantially different from the estimate of the effect.  Very low quality: we have very little confidence in the effect estimate; the true effect is likely to be substantially different from the estimate of effect.

^aOnly one outcome measure is reported for each outcome in this table (although further outcome measures were collected by the studies). Outcomes Measures were chosen based on how clinically meaningful they were.  ^b7.5 to 10.7 months after the baseline assessment.  ^cDowngraded one level for risk of bias (rated as unclear or high risk of bias on 4/7 domains).  ^dDowngraded two levels for imprecision due to small sample size, wide CI and only one trial identified for comparison.